LSCS & VBACKishore SROman Medical College

Textbook of Obstetrics by Sheila BalakrishnanCh 53 & 37

Introduction•Caesarean Section is a delivery of a

viable fetus through an incision in abdominal wall and intact uterus.

•Most common operation performed worldwide.

•Primary Caesarean is the first CS to be done on a patient, while Secondary Caesarean is the repeat procedure.

Indications for Caesarean Section• Previous C.S• Dystocia or dysfunctional labour:• Cephalopelvic disproportion• Tumours complicating pregnancy• Fetal macrosomia• Malpresentations• Deep transverse arrest• Abnormal uterine action• Failed forceps or vacuum

• Failed induction• Fetal distress and cord prolapse

• Breech presentation (complicated breech and footling presentation

• Other fetal indication• Severe intrauterine growth restriction• Multiple pregnancy

• Antepartum hemorrhage:• Placenta praevia• Abruptio placenta• Vasa praevia

• Maternal problems:• Elderly nullipara• Prolonged period of infertility or pregnancy

following in vitro fertilization• Bad obstetric history• Severe preeclampsia and diabetes

•Caesarean Section on request.

Most Common Indications (85% of the cases)•Previous CS (most common)•Dystocia•Fetal distress•Breech Presentation

Lower Segment Caesarean Section (LSCS)•A lower (uterine) segment Caesarean

section (LSCS) is the most commonly used type of Caesarean section used today.

• It includes a transverse cut just above the edge of the bladder and results in less blood loss and is easier to repair than other types of Caesarean sections.

•The advantage is that the healing of the lower segment is better as it is quiescent and high tensile strength.

Preparing the patient for LSCS

•Cross matched blood• Introduction of indwelling catheter •Skin prepared by antiseptic solution and

draped•Prophylactic antibiotics to prevent puerperal

sepsis.•Left lateral tilt to reduce aortocaval

compression and risk of supine hypotension.•Thromboprophylaxis for high risk patients.•Anesthesia, Regional is always better(spinal

or epidural)• In emergency CS, prevention of Mendelson’s

syndrome by Sellick manoeuvre and NGT aspiration.

Abdominal Incisions

•Pfannensteil Incision▫Most commonly used▫Transverse curvilinear incision just above the

pubic hairline.• Joel Cohen Incision▫A modified transverse incision placed about 3 cm

below the line joining the anterior superior iliac spines.

▫Higher than the Pfannensteil incision & not curved.•Maylard Incision ▫Where more exposure needed in a transverse

incision•Midline Vertical Incision

Procedure

•Uterine Incision∙Correct any dextrorotation∙Visualize the lower segment (Doyens

retractor)∙Loose peritoneum is divided transversely

and separated from the bladder by blunt incision

∙Small incision made in the lower segment and extended laterally using scissors.

•Delivery of the Baby •Hand slipped into the uterine cavity and

head is gently levered out.•Fundal Pressure maybe exerted on fetal

buttocks•Mouth and nose are suctioned to prevent

aspiration and the rest of the body is delivered by gentle traction.

•The umbilical cord is doubly clamped.

•LSCS Complete Video

• If the presentation is breech,▫The feet are hooked out.▫The rest of the baby delivered as in case of

a vaginal breech delivery.▫Breech delivery via LSCS

•Deeply Impacted head,▫The head may deeply impacted in

midpelvis with a thinned out lower segment.

▫Patwardhan method can be used in deeply impacted head.

•Transverse or Oblique lie,▫Corrected to a longitudinal lie before the

uterine incision is made.• If transverse lie with ruptured membranes

and an undeveloped lower segment,▫Extension of the uterine incision may be

needed• In case of dorsoinferior position with

rupture membranes, ▫More difficulty and this is one situation

where a transverse incision considered

•Closure of uterine incision▫Oxytocin infusion is started.▫Placenta and membranes are removed by

controlled cord traction. ▫The uterine edges are held with Allis forceps

or green-Armytage forceps.▫The uterine incision is closed in two layers of

continuous suture▫It is important that the two angles and any

other bleeding points be securely ligated.▫Haemostasis is ensured.▫The tubes and ovaries are inspected.

•Closure of the Abdomen▫Closed in layers after confirming mop and

instrument count.▫The parietal peritoneum need not be closed.▫The rectus sheath is carefully approximated

with delayed absorbable sutures to minimize the chance of wound dehiscence.

▫The skin approximated with mattress sutures, a subcuticular suture or clips.

Post Operative Care

•First 6-8hrs, monitor the vitals and look for vaginal bleeding and condition of the uterus.

•First Day, paraenteral fluids are given, blood transfusion if needed, antibiotics, thromboprophylaxis, breast feeding after 4hrs & oral fluid started after 6hrs.

•Second day, catheter and dressing removed and early ambulation.

•Third day, light solid diet can be started & laxative *if.

Other Types of Caesarean Sections• Inductions: constricting ring, lower segment

not formed & prematurity• Incision can extend downward (cervix ,

vagina, bladder) & increased chance of rupture in next pregnancy if incision extend to upper segment

Lower Segment Vertical Incision

• Indications: Unapproachable lower segment, cervix ca, ant placenta previa with previous CS, some cases of transverse lie with ruptured membrane & conjoined twins

• Healing is difficult, scar rupture is more in next pregnancy

Classical Caesarean Section

• Method of dealing with severe infection Extraperitoneal Caesarean Section

• Done as a life saving measures for severe atonic PPH & ruptured uterus, adherent placenta, multiple large myomas, severe sepsis and Ca in situ of the cervix

Caesarean Hysterectomy

• Emergency Cs in a women who has had a cardiac arrest to save a live fetus

Perimortem Caesarean Section

ComplicationsLATE SEQUELAE POSTOPERATIV

E INTRAOPERATI

VE Secondary PPH

Incisional hernia

Placenta previa & adherent placenta in next pregnancy

Vesicovaginal fistula

Scar rupture in next pregnancyIncreased incidence of Bladder injury at repeated CS

Paralytic ileus

DVT and PE

Infections, Peritonitis and Pelvic abscess

Wound dehiscence

Respiratory complications

Pelvic thrombophlebitis

Primary hemorrhage

Injury to internal organs

Injury to baby

Difficulty in delivery of head

Anesthesia complications:

-Aspiration-Mendelson’s syndrome

-Hypotension-Cardiac arrest

Questions?

Q. All the following are indications for a Caesarean section excepta) Abruptio placentab) Footling breechc) Placenta Percretad) Untreated Stage 1 Carcinoma cervixe) Active Genital herpes

Vaginal Birth After C-Section (VBAC)

•Once A C-section is not always a C-section • If the Patient had a cesarean delivery

before, she may be able to deliver your next baby vaginally. This is called vaginal birth after cesarean, or VBAC

Risks Involved

•Scar rupture▫More chance of rupture with a classical

section scar•Adherent placenta▫Risk of morbid adherence of placenta

increases with each CS.▫Risk of severe PPH and caesarean

hysterectomy is increased•Operative interference•Peripartum hysterectomy

Management

•Elective Caesarean Section•Trial of Labour after Caesarean (TOLAC)▫Ultrasound is of importance▫Myometrial thickness is 3.5mm or more

there is Low risk of uterine rupture.▫To assess placental location

Contraindications to VBAC

•Previous classical incision•Previous two LSCS•Previous inverted T incision•Previous low vertical incision•Malpresentations•Cephalopelvic disproportion•Multiple Pregnancy•Patient’s refuse to undergo trial of labour

Selection of CasesPrevious History• Type of incision• Prior indication• Prior vaginal delivery• Interpregnancy

interval >6months

Present Pregnancy• No medical or

Obstetric complications• Vertex presentation• Average sized baby• No CPD• Patient preference

Labour• Institutional delivery• Spontaneous onset of

labour• Continuous CTG• Emergency CS ready• Blood bank

Management • Informed consent•Monitoring•Delivery•Signs of Scar dehiscence• If Intrauterine fetal demise,▫Oral mifepristone can be used alone for

indication of labour in this case

Thank you